8.4 AI Q&A

Define maintenance treatment in asthma.

Medication taken daily regardless of symptoms to maintain control.

Describes frequency NOT class

Define controller therapy in asthma.

An inhaled corticosteroid-containing regimen used to reduce airway inflammation and future risk.

Define reliever therapy in asthma.

As‑needed medication for breakthrough symptoms; also used before anticipated exercise.

“Rescue” Inhaler

Anti-inflammatory Reliever (AIR)

ICS + rapid acting bronchodilator

Describe SMART (also called MART).

Use of an ICS‑formoterol inhaler for both daily maintenance and as‑needed relief with one device.

State the maximum total daily inhalations allowed with SMART.

Up to 8 inhalations/day for ages 6-11 and up to 12 inhalations/day for adolescents/adults (includes maintenance plus reliever doses).

Why is LABA monotherapy contraindicated in asthma?

It increases severe exacerbations and asthma‑related hospitalizations/deaths; LABAs must be paired with an ICS.

ICS MOA

Decrease inflammatory mediators, induce vasoconstriction to reduce mucosal edema, and provide local immunosuppression.

What are ICS place in therapy?

Maintenance; MAINSTAY of asthma

List common local adverse effects of inhaled corticosteroids and one prevention tip.

Oral candidiasis and dysphonia; rinse mouth with water and spit after each use.

URTI, sinusitis, cough, headache

Hypercortisolism/adrenal suppression, ↓BMD, glaucoma/cataracts

ICSs end with what?

-onide

-asone

What is the dosing principle for ICS to minimize adverse effects?

Use the lowest dose that achieves symptom control.

What monitoring is recommended with ICS use?

Track growth velocity over time.

FEV1 and peak flow

SABA MOA

Relax bronchial smooth muscle through beta-2 receptors

State the primary role of SABAs in asthma therapy.

Rapid bronchodilation reliever for acute bronchospasm and as adjunct to controller therapy.

SABA adverse effects

Palpitations, chest pain, tachycardia, tremor, nervousness

Why is SABA overuse dangerous?

It signals poor control and increases risk of severe exacerbations and mortality.

Name three monitoring items for SABA therapy.

– Heart rate, blood pressure, ECG

– Inhaler technique +/- spacing device

– Airway symptoms and frequency of use

What is the role of ICS/LABA combinations in asthma?

Controller therapy that combines anti‑inflammatory effect with long‑acting bronchodilation.

What should NOT be used as monotherapy?

LABA *************

What are adverse effects and monitoring for ICS+LABA?

Same for ICS and LABA

Which ICS/LABA combinations can be used for SMART?

Formoterol‑containing products (e.g., budesonide/formoterol; mometasone/formoterol when specified by guideline).

How should an ICS‑formoterol reliever be paired with maintenance therapy?

If used as reliever, the maintenance inhaler must be the same ICS‑formoterol; do not mix with a different ICS/LABA.

When are LAMAs considered in asthma management?

For persistent symptoms after optimizing ICS‑LABA; may be added to ICS‑LABA.

Albuterol + Budesonide is an example of what?

SABA + ICS

ICS + SABA place in therapy

Reliever: Track 2 alternative

LAMA MOA

Antagonize type 3 muscarinic receptors in bronchial smooth muscle → relaxation

LAMA place in therapy

Maintenance; Uncontrolled persistent asthma in combo wi/ LAMA+ICS or LAMA+ICS+LABA

Name two cautions for LAMA therapy.

Use caution in glaucoma or urinary retention due to anticholinergic effects.

What is another side effect of LAMA?

Dry mouth

What should be monitored for in LAMA?

Moderate to severe renal impairment increases anticholinergic effect

Leukotrine modifiers MOA

– Interfere with inflammatory cells

– Reduce inflammatory allergic component

What is the place of leukotriene modifiers in chronic asthma?

Adjunctive maintenance for persistent asthma,

Allergic component of asthma

How well do Leukotrine mediators handle exercise induced bronchospasms?

SABAs are more effective with faster onset

What black box warning applies to montelukast?

Risk of serious neuropsychiatric events; use with caution and monitor patients.

Agitation, aggression, anxiousness, depression, sleep disturbances, suicidal thoughts

Leukotriene modifiers adverse effects

URTI, fever, headache, pharyngitis, cough

Which leukotriene modifier requires LFT monitoring and why?

Zafirlukast due to hepatotoxicity risk; discontinue if injury occurs.

Lung function tests

What are examples of systemic corticosteroids?

• Hydrocortisone

• Prednisone

• Methylprednisone

• Dexamethasone

Ends w/ -sone

Systemic Corticosteroids MOA

Decreases inflammation, suppresses immune system

Systemic corticosteroids can be used for maintenance and asthma exacerbations less than _____ days

7

Acute adverse effects of SCS?

GI bleeding, sepsis, pneumonia

Adverse events of chronic SCS use?

Adrenal suppression, osteoporosis, HTN, many, many more

Name one systemic risk associated with repeated short OCS courses.

Dose‑dependent increases in diabetes, heart failure, osteoporosis, and other conditions over a lifetime.

What should be monitored for with systemic corticosteroids?

Chronic use vs. asthma control

Biological agents are used when in asthma therapy? (2)

Maintenance with severe/persistent asthma

Th2 cell inflammatory phenotype

Adverse effects of Xolair (omalizumab)

anaphylaxis

Injection site reactions, headache, dizziness

What should be monitored for with biological agents?

– Parasitic infection risk/infection

– Xolair – weight + pre-dose IgE concentration

Allergen immunotherapy/shot MOA

gradually increasing dose of allergen and can be used to treat the allergic component of asthma

Adverse effects of Subcutaneous Immunotherapy (SCIT)

itching, pain, erythema

Adverse effects of Sublingual Immunotherapy (SLIT)

oral irritation/itching

Patient should be monitored for how many minutes post allergy shot?

30 minutes post administration

Asthma patients should remain up to date on what?

Vaccinations : influenza and covid which can be given on the same day

Four Cs of choosing an inhaler

Choose

Check

Correct

Confirm

Define asthma control per assessment framework.

Degree to which symptoms and variable expiratory airflow are absent or reduced by treatment.

Name the two domains that must always be assessed in asthma control.

Current symptom control and future risk of adverse outcomes.

What 4 things are used to assess asthma control

Symptom control, risk of adverse outcomes, lung function, and asthma severity

List the four GINA symptom control questions over the prior 4 weeks.

Daytime symptoms >2/week

Any night awakening

Reliever needed >2/week (excluding pre‑exercise and SMART nuance based on saba),

Any activity limitation.

Are asthma symptoms alone sufficient to assess asthma?

NO

Why can symptom control and future risk be discordant?

A patient may be asymptomatic yet remain at high risk for exacerbations, lung function decline, or medication AEs.

When should FEV1 be assessed in ongoing care?

At diagnosis, after 3-6 months on controller medication, and periodically thereafter (typically every 1-2 years).

Low FEV1 predicts what?

Risk of asthma exacrebations

What should be done if a patient has normal FEV1 but is still symtomatic?

consider alternative causes

Persistent bronchodilator responsiveness indicates what?

uncontrolled asthma

How is peak expiratory flow used short term?

treatment response, evaluate triggers, establish asthma action plan baseline

Peak expiratory flow is only recommended long term in what patients?

Only recommended in patients with severe asthma

What defines mild vs. moderate vs. severe asthma severity (retrospective)?

Mild: controlled on as‑needed low‑dose ICS‑formoterol or low‑dose ICS+SABA

Moderate: controlled on Step 3-4 regimens; Low/Medium-dose ICS LABA

Severe: uncontrolled on or requiring high‑dose ICS‑LABA. Controlled with ICS +LABA ± biologics. Other causes excluded

Goals of asthma therapy

Prevent deaths, minimize exacerbations, normalize activity/sleep, optimize lung function, and minimize side effects using the lowest effective regimen.

Identify patients goals

What should be assessed in every asthma patient?

Symptom control AND risk of adverse outcomes

What is the preferred initial treatment for adults/adolescents with infrequent symptoms (<2/week)? Step 1

As‑needed low‑dose ICS/formoterol.

What is the alternative treatment for adults/adolescents with infrequent symptoms (<2/week)? Step 1

Low dose ICS taken whenever SABA is needed/used

What consists of step 2 in adults/adolescents?

Asthma symptoms less than 3-5 days per week, with normal or mildly reduced lung function

What is the preferred treatment for Step 2 in adults/adolescents?

As‑needed low‑dose ICS/formoterol

Step 2 alternative track

Low dose ICS daily + SABA PRN

What are symptoms of step 3 in people 12 and over? 3 possibilities

Asthma symptoms most days (4-5 days per week) OR ≥1x/week
nighttime awakening, OR with reduced lung function

What is initiated at Step 3 for adults/adolescents?

Low dose ICS/formoterol daily plus PRN

Step 3 alternative treatment for 12 and older? 2 possible options

Medium dose ICS daily + SABA PRN
*ICS/SABA PRN

OR

Low dose ICS/LABA daily + SABA PRN 

Symptoms of step 4 in those 12 and older?

Daily symptoms, ≥1x/week nighttime awakening, AND low lung function

Initial asthma presentation severely uncontrolled OR with a recent
exacerbation

What is preferred at Step 4 for adults/adolescents with daily symptoms or weekly night awakenings?

Medium‑dose ICS/formoterol daily and PRN

± oral corticosteroid

What is the alternative step 4 route for people 12 and older?

Medium dose ICS/LABA daily + SABA PRN

OR

High dose ICS/LABA daily + SABA PRN +/- oral corticosteroids
*ICS/SABA PRN (as possible reliever)

For asthma treatment of people 12 and older when is daily medication introduced on the preferred step vs alternative step?

Step 3 vs step 2

On the alternative track for people 12 and older when can ICS + SABA no longer be taken as monitherapy?

Step 4

Presenting symptoms for step 1 ages 6-11

Symptoms 2 or less days/week

Step 1 preferred treatment ages 6-11

Low dose ICS taken whenever SABA is needed/used

Step 2 symptoms ages 6-11

Asthma symptoms 2-5 days per week

• in contrast, adults could present w/ normal or slightly reduced lung function

Step 2 treatment ages 6-11

Low dose ICS daily + SABA PRN

What are three preferred options at Step 3 for children 6-11 years?

Low dose ICS/LABA daily + SABA PRN
OR
Medium dose ICS daily + SABA PRN
OR
Very low dose ICS/formoterol daily + PRN

Step 4 ages 6-11 (2)

Medium dose ICS/LABA daily + SABA PRN
Low dose ICS/formoterol daily + PRN
+/- oral corticosteroids

Children aged 6-11 should not be given what?

High dose ics/LABA

Before stepping up therapy, what must always be checked?

Inhaler technique, adherence, modifiable risk factors, comorbidities, and diagnostic certainty.

What is a short‑term step‑up?

Temporary ICS dose increase for ~1-2 weeks for factors like viral infection or seasonal allergens.

When should therapy be stepped down?

After ≥2-3 months of good control and stable lung function to reach the minimum effective dose; do not stop ICS.

What should not be done during step down therapy?

ICS therapy should not be stopped

Step down should not happen at inappropriate times ie pregnancy

Define an asthma exacerbation in patient‑friendly terms.

A flare‑up: progressive worsening of symptoms with decreased lung function requiring a change in treatment.

Common causes of exacerbation?

– Viral respiratory infections

– Environmental allergens

– Poor technique/adherence with ICS

– Idiopathic

How to treat kids younger than 5?

1: SABA PRN

2: Low dose ICS + SABA prn

Step 3: Double low dose

Step 4: continue controller and refer for specialist assessment

_______ has the most positive safety data

Budesonide

When should you see full benefit after initiating controller therapy?

3-4 months

When should you follow up with provider regarding treatment?

Follow-up with provider within 1-3 months after treatment
initiation and every 3-12 months thereafter

What should be assessed at follow up? (4)

– Symptom frequency
– Risk factors and occurrence of exacerbations
– Treatment side effects
– Inhaler technique and adherence